Womens Fitness Questionnaire

Please fill out a questionnaire form and we will get in touch with you as soon as possible. Take your time answering the questions, the more information you share with us the more we will understand how to assist you to reach your health and wellness goals.

Step 1 of 5 – Your info

20%

Name*

FirstLast

Email*

Enter EmailConfirm Email

Phone

Age*

Height*

Weight*

Occupation*

Health and fitness Concerns*

Health and fitness Goals*

How often do you focus on your health and fitness concerns?*

Never

Rarely

Sometimes

Regularily

Immunization History*

Within the last 3 – 6 months

Within the last 6 – 12 months

Within the last 1 – 3 years

Within the last 3 – 10 years

No, Never

Do you currently have any Silver, or Mercury dental amalgam fillings?*

Yes

No

How many?

How long have you had these filings?

Medications & Supplements: Please list any medications and/or supplements that you are currently taking or have taken in the past.*

Medications: Names and Dosages

Supplements: Names and Dosages*

Have your medications or supplements ever caused you side effects or health problems?*

Yes

No

How much Sleep do you get per 24 hrs?*

10 hrs a day

8-10

6-8

6 or less

Do you have trouble sleeping?*

Yes

No

Do you feel rested upon awakening?*

Yes

No

Do you have problems with insomnia?*

Yes

No

Do you snore?*

Yes

No

Do you use sleeping aids?*

Yes

No

Do you use tobacco?*

Yes

No

How many years have you been smoking?

Are you exposed to second hand smoke?*

Yes

No

What is your diet type? *

How many drinks of alcoholic per week?*

none

1 – 3 drinks

4 – 7 drinks

7 – 10

More than 10

How many cups of coffee per week?*

None

1 – 3

4 – 6

7 – 10

How many drinks of soda or concentrated juice per week?*

None

1 – 3

4 – 6

7 – 10

What is a typical day of eating for you? *

What are your most common sources of protein, carbohydrates and fat? *

How many times per day do you have a bowel movement?

Please consider carefully before answering this question: Any other important information for us to know?